PEDIATRIC PAIN ASSESSMENT AND MANAGEMENT GUIDE

These cards were designed to guide a health care provider’s initial assessment when screening children for pain issues.

The Oregon Board of Nursing position statement for Pain Management1 asserts that the nurse is responsible for maintaining the knowledge and skills necessary to coordinate optimal pain management. The nurse is accountable for implementing the pain management plan, utilizing his/her knowledge base and documented assessment of the child’s needs. The scope of the nurse’s practice and the practice setting determine the interventions that the nurse may carry out but all nurses are accountable for doing an initial assessment and for documenting the assessment, interventions and an evaluation of the effectiveness of interventions. The Board of Nursing regulation states further that the assessment, intervention and ongoing changes to the plan of care must be documented in a clear and concise manner.

Documentation must include the date of the assessment, precipitating factors or causes for the child’s pain, previous evaluations and treatment, the effectives of past treatment, severity, intensity, frequency and factors that exacerbate or ameliorate the pain. The nurse should use a standardized tool and document which tool was used. The nurse should also document that she assessed the impact of pain on the child’s daily activities, school performance and sleep patterns.

Possible interventions that are appropriate for nurses working in community settings might include pain management, health education, referral to a primary provider or pain specialist, medication administration (in the school setting) and parent education. The nurse may also participate in the formulation of a 504 plan to allow accommodations for a child at school.

1 Oregon State Board of Nursing Position Statement for Pain Management Adopted 6/17/04 accessed online 4/21/2011.

For additional copies contact the CaCoon ProgramOregon Center for Children and Youth with Special Health Needs (OCCYSHN)

Oregon Health & Science UniversityMailcode CDRC

PO Box 574Portland, OR 97207-0574

or

Fax 503-494-2755 Website: www.occyshn.org

Copyright © 2005, 2011 by Oregon Health & Science University, Child Development and Rehabilitation Center,

Oregon Center for Children and Youth with Special Health Needs

All Rights Reserved

The cards were developed by the Oregon Center for Children and Youth with Special Health Needs located at the Child Development and Rehabilitation Center,

Oregon Health & Science University, April 2011 , in collaboration with nursing staff from OHSU, Multnomah County Health Department, Multnomah County Educational Service District, the Oregon Pain Commission, and a parent of two special needs children.

PAIN ASSESSMENT (1 OF 2)

Outcomes:1. Child (all ages) will have an assessment of their pain status at the time of the initial nursing assessment and

reassessment as needed.2. Child will have access to a medical evaluation of their pain.3. Child and family will be offered effective pain relief strategies.4. Child will experience an increase in function and a decrease in pain.

Observations: Does the child exhibit verbal or nonverbal pain cues? Are parents and other caregivers aware of child’s pain cues? Does child’s environment contribute to decreased or increased pain-positioning, adaptive equipment, environmental temperature, adequate food and fluids available?

Behavioral Cues in Infants: Grimacing, brow bulge, deepened nasolabial furrows, quivering chin, open or pursed lips, reflexive limb withdrawal, body posturing (squirming, kicking, trunk arching, whimpering to high pitched cry, breath holding .)

Physiological Cues: Skin color changes, palmar sweating, decreased O2 saturation, increased heart rate, blood pressure and respirations.

Inquire about parent and child/adolescent concerns

For Infant/Toddler Assess: y Whether underlying condition is being well managed y Parental understanding of importance of preventive

health care, ability to advocate for child in health system y Parental knowledge of emergency and illness care (signs/

symptoms of pain) emergency numbers available y Parent’s awareness of pain cues y Use appropriate pain scale to assess pain - FACES, FLACC y Observe for nonverbal pain cues - does child have a

condition where communication of pain is limited

y Location, frequency, triggers of pain y Degree to which pain interferes with daily activities,

quality of life and sleep patterns y Presence of acute or chronic condition or injury that

could contribute to pain y Presence of environmental hazards that may

contribute to pain and knowledge to modify environment for infant safety; appropriate car seat.

y Adequacy of pain relief from medication or other strategies

y Cultural and family beliefs about pain and methods of pain control

PAIN ASSESSMENT (2 OF 2)

For School-age Child Assess: y Child’s knowledge of emergency care, how to access

health care, as well as child’s ability to participate in/manage own personal care, healthy behaviors (helmet, seat belts, exercise)

y Child’s ability to identify pain triggers, frequency, quality and severity of pain

y Use appropriate pain scale to assess child’s pain y Child’s ability to identify and perform pain relief strategies y Parent’s ability to assist child with pain relief - direct

interventions, making doctor appointments for child, providing environmental modifications

y Adequacy of management of child’s underlying condition y Child’s attendance at school, ability to complete

homework y Child’s ability to participate in daily activities, chores,

social activities

For Adolescent Assess: y Access to health care (primary care, dental, crisis care,

public services), knowledge of own health issues and status (health history, immunizations, etc.), health status is within normal range for age, development and potential

y Adolescent beliefs about pain and their response to pain y Degree to which pain interferes with daily activities and

quality of life

y Adolescent’s ability to identify pain triggers and appropriate relief strategies

y Adolescent’s ability to direct their own health care – make appointments, refill prescriptions, discuss their preferences for pain relief with providers

y Parental understanding of adolescent health needs y Parent available to help adolescent manage pain

when needed

For the Child with Special Needs Assess: y Access to recommended specialty care (services

available and financially feasible), including primary care, access to appropriate specialists for their condition, access to pain clinic

y The need for special safety considerations (use of oxygen, adaptive car seat, helmet), plan for emergency or acute exacerbation of illness, parent’s ability to recognize and prevent secondary conditions such as pain, child’s participation in own health care.

y Child’s access to therapists (OT, speech, PT) who can assess and assist with pain relief.

y Child’s access to complementary therapies. y Adequacy of pain management while traveling

(enough meds, emergencies, etc.)

ASSESSMENT TOOLS

Wong-Baker FACES Pain Rating Scale

0 2 4 6 8 10

no hurt hurts little bit hurts little more hurts even more hurts whole lot hurts worst

Original instructions:Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because he doesn’t hurt at all. Face 2 hurts just a little bit. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don’t have to be crying to feel this bad. Ask the person to choose the face that best describes how he is feeling. Rating scale is recommended for persons age 3 years and older.

Brief word instructions: Point to each face using the words to describe the pain intensity. Ask the child to choose the face that best describes own pain and record the appropriate number.

From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P. (2001): Wong’s Essentials of Pediatric Nursing (6th ed.) (p.1301). St. Louis, MO: Mosby.

Reprinted by permission.

FLACC Scale

Category Scoring

0 1 2

Face No particular expression or smile Occasional grimace/frown; withdrawn or disinterested; appears sad or worried

Frequent/constant quivering chin, clenched jaw; distressed-looking face; expression of fright or panic

Legs Normal position or relaxed; usual tone and motion to limbs

Uneasy, restless, tense; occasional tremors

Kicking, or legs drawn up; marked increase in spasticity, constant tremors or jerking

Activity Lying quietly, normal position, moves easily; regular, rhythmic respirations

Squirming, shifting back and forth, tense or guarded movements; mildly agitated (e.g. head back and forth, aggression); shallow, splinting respirations, intermittent sighs

Arched, rigid or jerking; severe agitation; head banging; shivering (not rigors); breath holding, gasping or sharp intake of breaths, severe splinting

Cry No cry/verbalization (awake or asleep)

Moans or whimpers; occasional complaint; occasional verbal outburst or grunt

Crying steadily, screams or sobs, frequent complaints; repeated outbursts, constant grunting

Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0-2, which results in a total score between zero and ten.

Reprinted from Pediatric Nursing, 1997, Volume 23, Number 3, p. 293-297. Reprinted with permission of the publisher, Jannetti Publications, Inc., East Holly Avenue, Box 56, Pitman, NJ 08071-0056; (856) 256-2300; FAX (856) 589-7463; Web site: www.pediatricnursing.net; For a sample copy of the journal, please contact the publisher. Revised from Pediatric Anesthesia 2006 16: 258–265; “The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment“ Shobha Malviya MD, Terri Voepel-Lewis MSN RN, Constance Burke BSN RN, Sandra Merkel MS RN & Alan R. Tait PhD.

Revised 4/21/2011

Numeric Rating Scale (NRS)

No Pain Moderate Pain Worst Pain

0 1 2 3 4 5 6 7 8 9 10

Questions to ask about cultural beliefs about pain2:

y What do you call your pain? y Do you have a name for it? y What do you think caused your pain? y Why do you think it started when it did? y What does your pain do to you? y How does it work? y How severe is your pain? y Do you think it will have a short or long course? y What are the most important results you expect to receive from the treatment? y What are the main problems that your pain has caused you? y What do you fear most about your pain?

2Weissman, David E., Gordon, Deborah.& Bidar-Sielaff, Shiva. Cultural aspects of Pain Management http://www.eperc.mcw.edu/

PAIN MANAGEMENT

y Use therapeutic communication strategies to acknowledge the pain experience and convey acceptance of child’s response to pain.

y Explore child and family’s knowledge and beliefs about pain.

y Determine impact of pain on quality of life. y Consider cultural influences on pain response. y Educate parents and other caregivers to recognize pain

cues in their child and to intervene appropriately. y Utilize a developmentally appropriate assessment

method that allows for monitoring of change in pain and that will assist in identifying actual and potential precipitating factors.

y Assist child and family to seek and obtain treatment for pain.

y Teach child and/or parents how to access health care. y Assist family to locate primary and specialty physicians. y Assist family to apply for financial assistance if necessary. y Collaborate with the child, family and health professionals

to select and implement pain relief strategies. y Communicate with child’s physician and other health

care providers regarding status of pain and effectiveness of interventions.

y Inform physician of complementary therapies that family is using and effectiveness of these strategies.

y Teach principles of pain management. y Evaluate effectiveness of pain control strategies.

y Inform parents about the use of nonpharmacological techniques - positioning, equipment modifications, music therapy, distraction, play therapy, acupressure, hot/cold application and massage, biofeedback, TENS, hypnosis, relaxation, guided imagery.

y Monitor child and family satisfaction with pain management at specified intervals.

y Refer to child’s PT or OT for evaluation of adaptive or mobility aids that may reduce pain. They can evaluate current equipment that may be contributing to increased pain.

y Evaluate and modify daily routines and/or work routines in order to reduce pain.

y Inform parents and child how to accomplish pain management while traveling (enough medications, emergencies, etc.)

y Refer child to school nurse or appropriate school personnel for development of a 504 plan if accommodations are needed in school.

y Develop agency (school district) policies and procedures for accurate and safe administration of medications. Policies must include consideration of whether state laws permit storage and administration of opioids and other controlled medications at school.

y Follow state regulations when delegating medication administration to school personnel who are not nurses.